Maternal cardiac function in twin pregnancy at 19-23 weeks' gestation.

OBJECTIVES: To compare maternal cardiovascular indices at 19-23 weeks' gestation between twin and singleton pregnancies and assess the impact of chorionicity on these parameters. METHODS: This was a prospective observational study in women with twin pregnancy attending for a hospital visit at 19 + 1 to 24 + 3 weeks' gestation. This visit included recording of maternal demographic characteristics and medical history and maternal cardiovascular assessment. In a previous study of 4795 women with singleton pregnancies at 19-23 weeks' gestation, multivariable linear regression models were fitted between the various cardiovascular indices and elements of maternal characteristics and medical history. In this study, we calculated multiples of the median (MoM) and delta values according to the singleton models and assessed the distributional properties of these MoM and delta values in twin as compared with singleton pregnancies. RESULTS: The study population of 155 women with twin pregnancy included 86 dichorionic and 69 monochorionic cases. In general, there was a similar distribution of maternal cardiovascular indices in monochorionic and dichorionic twin pregnancies. In both types of twin pregnancy, compared with singleton pregnancy, there was an increase in isovolumetric relaxation time, left atrial area and myocardial performance index, and a decrease in mitral valve E/A. Left ventricular mass indexed for body surface area and relative wall thickness were also increased in twin compared with singleton pregnancy. The magnitude of the increase in left atrial area was greater in dichorionic compared with monochorionic pregnancies. Additionally, mitral valve E was decreased and left atrial volume was increased in dichorionic but not in monochorionic pregnancies, while isovolumetric contraction time was increased in monochorionic but not in dichorionic pregnancies. Left ventricular myocardial deformation was similar between twin and singleton pregnancies. CONCLUSIONS: In twin pregnancies at mid-gestation, maternal systolic and diastolic function is reduced when compared with singletons. The patterns of cardiovascular adaptation are similar between monochorionic and dichorionic pregnancies and resemble those reported in uncomplicated singleton pregnancy later in gestation. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal loss after chorionic villus sampling in twin pregnancy.

OBJECTIVE: To estimate the chorionic villus sampling (CVS)-related risk of fetal loss in twin pregnancy after adjustment for chorionicity, nuchal translucency thickness (NT), intertwin discordance in crown-rump length (CRL), maternal demographic characteristics and serum pregnancy-associated plasma protein-A (PAPP-A) and free ß-human chorionic gonadotropin (ß-hCG). METHODS: This was a multicenter study from eight fetal medicine units in which the leadership were trained at the Harris Birthright Research Centre for Fetal Medicine in London, UK, and in which the protocols for screening, invasive testing and pregnancy management are similar. Data were obtained prospectively from women with twin pregnancy undergoing routine ultrasound examination at 11-13 weeks' gestation. Multivariable logistic regression analysis with backward stepwise elimination was used to examine whether CVS provided a significant independent contribution to the prediction of risk of fetal loss after adjusting for maternal and pregnancy characteristics, including maternal age, racial origin and weight, method of conception, smoking status, parity, chorionicity, intertwin discordance in CRL, fetal NT ≥ 95th percentile and free ß-hCG and PAPP-A multiples of the median. Similarly, within the CVS group, multivariable logistic regression analysis was used to investigate the effect of the number of intrauterine needle insertions and size of the needle on the risk of fetal loss. RESULTS: The study population of 8581 twin pregnancies undergoing ultrasound examination at 11-13 weeks' gestation included 316 dichorionic and 129 monochorionic twins that had CVS. First, in twin pregnancies undergoing CVS, compared to those not undergoing CVS, there was a 2-fold increased risk of fetal loss at < 24 weeks' gestation and of loss at any stage in pregnancy. Second, the factors providing a significant independent contribution to the prediction of miscarriage or fetal loss in twin pregnancy were increased maternal weight, black racial origin, monochorionicity, and more so monoamnionicity, large intertwin discordance in CRL and increased fetal NT, and, in the case of fetal loss at any stage, there was also a contribution from assisted conception and low serum PAPP-A. Third, after adjustment for maternal and pregnancy characteristics, CVS did not provide a significant contribution to the risk of fetal loss. Fourth, in twin pregnancies that had CVS, there was no significant contribution to fetal loss from the number of intrauterine needle insertions or needle size. CONCLUSION: The 2-fold increased risk of fetal loss following CVS in twin pregnancy can, to a great extent, be explained by maternal and pregnancy characteristics rather than the invasive procedure itself. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal cardiac function at 35-37 weeks' gestation in pregnancies that subsequently develop pre-eclampsia.

OBJECTIVE: To compare fetal cardiac morphology and function between pregnancies that subsequently developed pre-eclampsia (PE) and those that remained normotensive. METHODS: This was a prospective observational study in 1574 pregnancies at 35-37 weeks' gestation, including 76 that subsequently developed PE. We carried out comprehensive assessment of fetal cardiac morphology and function including novel imaging modalities, such as speckle-tracking echocardiography, and measured uterine artery pulsatility index, mean arterial pressure (MAP), serum placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and cerebroplacental ratio (CPR). The findings in the group that subsequently developed PE were compared to those in pregnancies that remained normotensive. RESULTS: In fetuses of mothers who subsequently developed PE, compared to those from normotensive pregnancies, there was a more globular right ventricle, as shown by reduced right ventricular sphericity index, reduced right ventricular systolic contractility, as shown by reduced global longitudinal strain, and reduced left ventricular diastolic function, as shown by increased E/A ratio. On multivariable regression analysis, these indices demonstrated an association with PE, independent of maternal characteristics and fetal size. In pregnancies that subsequently developed PE, compared to those that remained normotensive, MAP, sFlt-1 and the incidence of low birth weight were higher, whereas serum PlGF, CPR and the interval between assessment and delivery were lower. These findings demonstrate that, in pregnancies that develop PE, there is evidence of impaired placentation, reflected in low PlGF and reduced birth weight, placental ischemia, evidenced by increased sFlt-1 which becomes apparent in the interval of 2-4 weeks preceding the clinical onset of PE, and consequent fetal hypoxia-induced redistribution in the fetal circulation, reflected in the low CPR. CONCLUSION: Although the etiology of the observed fetal cardiac changes in pregnancies that subsequently develop PE remains unclear, it is possible that the reduction in right-heart systolic function is the consequence of high afterload due to increased placental resistance, whilst the early left ventricular diastolic changes could be due to fetal hypoxia-induced redistribution in the fetal circulation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical validation of bioreactance for the measurement of cardiac output in pregnancy.

Maternal cardiac dysfunction is associated with pre-eclampsia, fetal growth restriction and haemodynamic instability during obstetric anaesthesia. There is growing interest in the use of non-invasive cardiac output monitoring to guide antihypertensive and fluid therapies in obstetrics. The aim of this study was to validate thoracic bioreactance using the NICOM® instrument against transthoracic echocardiography in pregnant women, and to assess the effects of maternal characteristics on the absolute difference of stroke volume, cardiac output and heart rate. We performed a prospective study involving women with singleton pregnancies in each trimester. We recruited 56 women who were between 11 and 14 weeks gestation, 57 between 20 and 23 weeks, and 53 between 35 and 37 weeks. Cardiac output was assessed repeatedly and simultaneously over 5 min in the left lateral position with NICOM and echocardiography. The performance of NICOM was assessed by calculating bias, 95% limits of agreement and mean percentage difference relative to echocardiography. Multivariate regression analysis evaluated the effect of maternal characteristics on the absolute difference between echocardiography and NICOM. The mean percentage difference of cardiac output measurements between the two methods was ±17%, with mean bias of -0.13 l.min-1 and limits of agreement of -1.1 to 0.84; stroke volume measurements had a mean percentage difference of ±15%, with a mean bias of -0.8 ml (-10.9 to 12.6); and heart rate measurements had a mean percentage difference of ±6%, with a mean bias of -2.4 beats.min-1 (-6.9 to 2.0). Similar results were found when the analyses were confined to each individual trimester. The absolute difference between NICOM and echocardiography was not affected by maternal age, weight, height, race, systolic or diastolic blood pressure. In conclusion, NICOM demonstrated good agreement with echocardiography, and can be used in pregnancy for the measurement of cardiac function.

Hipertensión arterial no controlable en el primer trimestre de la gestación. Hiperparatiroidismo primario, a propósito de un caso / Uncontrollable hypertension in the first trimester of pregnancy. Primary hyperparathyroidism; a case report

Mujer de 28 años. Sin antecedentes médico-quirúrgicos de interés. Gestación actual gemelar bicorial-biamniótica espontánea. Ingresa con 9 semanas por vómitos incoercibles con diagnóstico de hiperemesis gravídica. Las tensiones arteriales se mantienen elevadas. Se inicia estudio de enfermedad hipertensiva y tratamiento, sin mejoría. En las analíticas destacan una calcemia y PTH muy elevada con fosforemia baja. Se completa estudio con ecografía de cuello informada como presencia de lesión hipoecoica inferior al lóbulo tiroideo derecho sugestiva de adenoma paratiroideo. Se confirma diagnóstico de hipercalcemia severa secundaria a hiperparatiroidismo primario por adenoma de paratiroides. Se decide realizar paratiroidectomía en segundo trimestre, tras la cual se produce descenso de la calcemia y control de la tensión arterial y del resto de clínica. Aunque es la causa más frecuente de hipercalcemia en la población general, se trata de una enfermedad poco frecuente en mujeres en edad fértil. Su incidencia aproximada durante el embarazo es de 8/10.000. Durante el embarazo se produce una transferencia de calcio y fósforo materno al feto, lo que provoca la supresión de la secreción de PTH fetal y el incremento de los valores de calcitonina. Se asocia a una alta morbimortalidad materno-fetal, con riesgo de nefrolitiasis, hiperemesis, HTA, gran morbilidad con aumento de riesgo de preeclampsia y de afección renal. Como complicaciones obstétricas destacan el aumento del riesgo de aborto, amenaza de parto pretérmino y el desarrollo de fetos con retraso del crecimiento intrauterino. Entre las medidas conservadoras de tratamiento se recomienda mantener una buena hidratación oral, limitar la ingesta de calcio y tratar los síntomas asociados. La paratiroidectomía es el tratamiento definitivo y se debe realizar en el segundo trimestre

Spontaneous dichorionic-diamniotic twin pregnancy. Patient is admitted at 9weeks pregnant due to uncontrollable vomiting and is diagnosed with hyperemesis gravidarum. Blood pressure remains high. Study of hypertensive disease and treatment initiated without improvement. Blood tests showed a very high serum calcium and PTH with low phosphoremia. Study is completed with neck ultrasound revealing a lower hypoechoic lesion of the right thyroid lobe suggestive of parathyroid adenoma. Diagnosis of severe hypercalcemia secondary to primary hyperparathyroidism due to parathyroid adenoma was confirmed. It was decided to perform a parathyroidectomy in the second trimester after which a decrease in serum calcium, control blood pressure and other symptoms was found. Although it is the most common cause of hypercalcemia in the general population, it is a rare condition in women of childbearing age. Its approximate incidence during pregnancy is 8/10,000. During pregnancy, maternal calcium and phosphorus is transferred to the fetus, which results in suppression of fetal PTH secretion and increased fetal calcitonin values. It is associated with high maternal and fetal morbidity and mortality and risk of nephrolithiasis, hyperemesis, hypertension, high morbidity with increased risk of preeclampsia and kidney disease. In the fetus, there is an increased risk of spontaneous abortion, intrauterine growth retardation and preterm birth. Among conservative treatment measures, it is recommended to maintain good oral hydration, limit calcium intake and treat associated symptoms. Parathyroidectomy is the definitive treatment and should be performed in the second trimester